Part 417 — Health Maintenance Organizations, Competitive Medical Plans, and Health Care Prepayment Plans
Subpart A — General Provisions
Subpart B — Qualified Health Maintenance Organizations: Services
- § 417.101— Health benefits plan: Basic health services.
- § 417.102— Health benefits plan: Supplemental health services.
- § 417.103— Providers of basic and supplemental health services.
- § 417.104— Payment for basic health services.
- § 417.105— Payment for supplemental health services.
- § 417.106— Quality assurance program; Availability, accessibility, and continuity of basic and supplemental health services.
Subpart C — Qualified Health Maintenance Organizations: Organization and Operation
Subpart D — Application for Federal Qualification
Subpart E — Inclusion of Qualified Health Maintenance Organizations in Employee Health Benefits Plans
- § 417.150— Definitions.
- § 417.151— Applicability.
- § 417.153— Offer of HMO alternative.
- § 417.155— How the HMO option must be included in the health benefits plan.
- § 417.156— When the HMO must be offered to employees.
- § 417.157— Contributions for the HMO alternative.
- § 417.158— Payroll deductions.
- § 417.159— Relationship of section 1310 of the Public Health Service Act to the National Labor Relations Act and the Railway Labor Act.
Subpart F — Continued Regulation of Federally Qualified Health Maintenance Organizations
- § 417.160— Applicability.
- § 417.161— Compliance with assurances.
- § 417.162— Reporting requirements.
- § 417.163— Enforcement procedures.
- § 417.164— Effect of revocation of qualification on inclusion in employee's health benefit plans.
- § 417.165— Reapplication for qualification.
- § 417.166— Waiver of assurances.
Subpart J — Qualifying Conditions for Medicare Contracts
- § 417.400— Basis and scope.
- § 417.401— Definitions.
- § 417.402— Effective date of initial regulations.
- § 417.404— General requirements.
- § 417.406— Application and determination.
- § 417.407— Requirements for a Competitive Medical Plan (CMP).
- § 417.408— Contract application process.
- § 417.410— Qualifying conditions: General rules.
- § 417.412— Qualifying condition: Administration and management.
- § 417.413— Qualifying condition: Operating experience and enrollment.
- § 417.414— Qualifying condition: Range of services.
- § 417.416— Qualifying condition: Furnishing of services.
- § 417.418— Qualifying condition: Quality assurance program.
Subpart K — Enrollment, Entitlement, and Disenrollment under Medicare Contract
- § 417.420— Basic rules on enrollment and entitlement.
- § 417.422— Eligibility to enroll in an HMO or CMP.
- § 417.423— Special rules: ESRD and hospice patients.
- § 417.424— Denial of enrollment.
- § 417.426— Open enrollment requirements.
- § 417.427— Extending MA and Part D program disclosure requirements to section 1876 cost contract plans.
- § 417.428— Marketing activities.
- § 417.430— Application procedures.
- § 417.432— Conversion of enrollment.
- § 417.434— Reenrollment.
- § 417.436— Rules for enrollees.
- § 417.440— Entitlement to health care services from an HMO or CMP.
- § 417.442— Risk HMO's and CMP's: Conditions for provision of additional benefits.
- § 417.444— Special rules for certain enrollees of risk HMOs and CMPs.
- § 417.448— Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.
- § 417.450— Effective date of coverage.
- § 417.452— Liability of Medicare enrollees.
- § 417.454— Charges to Medicare enrollees.
- § 417.456— Refunds to Medicare enrollees.
- § 417.458— Recoupment of uncollected deductible and coinsurance amounts.
- § 417.460— Disenrollment of beneficiaries by an HMO or CMP.
- § 417.461— Disenrollment by the enrollee.
- § 417.464— End of CMS's liability for payment: Disenrollment of beneficiaries and termination or default of contract.
Subpart L — Medicare Contract Requirements
- § 417.470— Basis and scope.
- § 417.472— Basic contract requirements.
- § 417.474— Effective date and term of contract.
- § 417.476— Waived conditions.
- § 417.478— Requirements of other laws and regulations.
- § 417.479— Requirements for physician incentive plans.
- § 417.480— Maintenance of records: Cost HMOs and CMPs.
- § 417.481— Maintenance of records: Risk HMOs and CMPs.
- § 417.482— Access to facilities and records.
- § 417.484— Requirement applicable to related entities.
- § 417.486— Disclosure of information and confidentiality.
- § 417.488— Notice of termination and of available alternatives: Risk contract.
- § 417.490— Renewal of contract.
- § 417.492— Nonrenewal of contract.
- § 417.494— Modification or termination of contract.
- § 417.496— Cost plan crosswalk.
- § 417.500— Intermediate sanctions for and civil monetary penalties against HMOs and CMPs.
Subpart M — Change of Ownership and Leasing of Facilities: Effect on Medicare Contract
Subpart N — Medicare Payment to HMOs and CMPs: General Rules
Subpart O — Medicare Payment: Cost Basis
- § 417.530— Basis and scope.
- § 417.531— Hospice care services.
- § 417.532— General considerations.
- § 417.533— Part B carrier responsibilities.
- § 417.534— Allowable costs.
- § 417.536— Cost payment principles.
- § 417.538— Enrollment and marketing costs.
- § 417.540— Enrollment costs.
- § 417.542— Reinsurance costs.
- § 417.544— Physicians' services furnished directly by the HMO or CMP.
- § 417.546— Physicians' services and other Part B supplier services furnished under arrangements.
- § 417.548— Provider services through arrangements.
- § 417.550— Special Medicare program requirements.
- § 417.552— Cost apportionment: General provisions.
- § 417.554— Apportionment: Provider services furnished directly by the HMO or CMP.
- § 417.556— Apportionment: Provider services furnished by the HMO or CMP through arrangements with others.
- § 417.558— Emergency, urgently needed, and out-of-area services for which the HMO or CMP accepts responsibility.
- § 417.560— Apportionment: Part B physician and supplier services.
- § 417.564— Apportionment and allocation of administrative and general costs.
- § 417.566— Other methods of allocation and apportionment.
- § 417.568— Adequate financial records, statistical data, and cost finding.
- § 417.570— Interim per capita payments.
- § 417.572— Budget and enrollment forecast and interim reports.
- § 417.574— Interim settlement.
- § 417.576— Final settlement.
Subpart P — Medicare Payment: Risk Basis
- § 417.580— Basis and scope.
- § 417.582— Definitions.
- § 417.584— Payment to HMOs or CMPs with risk contracts.
- § 417.585— Special rules: Hospice care.
- § 417.588— Computation of adjusted average per capita cost (AAPCC).
- § 417.590— Computation of the average of the per capita rates of payment.
- § 417.592— Additional benefits requirement.
- § 417.594— Computation of adjusted community rate (ACR).
- § 417.596— Establishment of a benefit stabilization fund.
- § 417.597— Withdrawal from a benefit stabilization fund.
- § 417.598— Annual enrollment reconciliation.
Subpart Q — Beneficiary Appeals
Subpart R — Medicare Contract Appeals
Subpart U — Health Care Prepayment Plans
- § 417.800— Payment to HCPPs: Definitions and basic rules.
- § 417.801— Agreements between CMS and health care prepayment plans.
- § 417.802— Allowable costs.
- § 417.804— Cost apportionment.
- § 417.806— Financial records, statistical data, and cost finding.
- § 417.808— Interim per capita payments.
- § 417.810— Final settlement.
- § 417.830— Scope of regulations on beneficiary appeals.
- § 417.832— Applicability of requirements and procedures.
- § 417.834— Responsibility for establishing administrative review procedures.
- § 417.836— Written description of administrative review procedures.
- § 417.838— Organization determinations.
- § 417.840— Administrative review procedures.